Basic Information
| Provider Information | |||||||||
| NPI: | 1518005610 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TERESA L JACKSON MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43100 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857333100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207223777 | ||||||||
| FaxNumber: | 5202966224 | ||||||||
| Practice Location | |||||||||
| Address1: | 1521 E TANGERINE RD | ||||||||
| Address2: | #331 | ||||||||
| City: | ORO VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857556225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205310700 | ||||||||
| FaxNumber: | 5205310705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5205310700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 32627 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.